Psychoanalysis

psychiatryWhen people ask what psychoanalysis is, they usually want to know about treatment. Psychoanalysis is based on the observation that individuals are often unaware of many of the factors that determine their emotions and behavior. These unconscious factors may create unhappiness, sometimes in the form of recognizable symptoms and at other times as troubling personality traits, difficulties in work or in love relationships, or disturbances in mood and self-esteem. Because these forces are unconscious, the advice of friends and family, the reading of self-help books, or even the most determined efforts of will often fail to provide relief.

Psychoanalytic treatment demonstrates how these unconscious factors affect current relationships and patterns of behavior, traces them back to their historical origins, shows how they have changed and developed over time, and helps the individual to deal better with the realities of adult life.

Analysis is an intimate partnership, in the course of which the patient becomes aware of the underlying sources of his or her difficulties not simply intellectually, but emotionally – by re-experiencing them with the analyst. Typically, the patient comes four or five times a week, lies on a couch, and attempts to say everything that comes to mind. These conditions create the analytic setting, which permits the emergence of aspects of the mind not accessible to other methods of observation. As the patient speaks, hints of the unconscious sources of current difficulties gradually begin to appear – in certain repetitive patterns of behavior, in the topics that the patient finds hard to talk about, in the ways the patient relates to the analyst, etc.

The analyst helps elucidate these for the patient, who refines, corrects, rejects, and adds further thoughts and feelings. During the years that an analysis takes place, the patient wrestles with these insights, going over them repeatedly with the analyst and experiencing them in daily life, in fantasies, and in dreams. Patient and analyst join in efforts not only to modify crippling life patterns and remove incapacitating symptoms, but also to expand the freedom to work and to love. When successful, the patient’s life – his or her behavior, relationships, sense of self – changes in deep and abiding way. Not all patients benefit from psychoanalytic treatment. Useful attributes to have to benefit from psychoanalysis are:
• The capacity to relate well enough to form an effective working relationship with the analyst. This relationship is called a therapeutic alliance.
• At least average intelligence and a basic understanding of psychological theory.
• The ability to tolerate frustration, sadness, and other painful emotions.
• The capacity to distinguish between reality and fantasy.

People considered best suited to psychoanalytic treatment include those with depression, character disorders, neurotic conflicts, and chronic relationship problems. When the patient’s conflicts are long-standing and deeply entrenched in his or her personality, psychoanalysis may be preferable to psychoanalytic psychotherapy, because of its greater depth.

Purpose

The original theories that underlie psychoanalysis are often attributed to Dr. Sigmund Freud (1856-1939), a Viennese physician, during the early years of the twentieth century. Freud’s discoveries were made in the context of his research into hypnosis. The goal of psychoanalysis is the uncovering and resolution of the patient’s internal conflicts. The treatment focuses on the formation of an intense relationship between the therapist and patient, which is analyzed and discussed in order to deepen the patient’s insight into his or her problems.

Precautions

Psychoanalysis is not usually considered suitable for patients suffering from severe depression or such psychotic disorders as schizophrenia, although some analysts have successfully treated patients with psychoses. It is also not appropriate for people with addictions or substance dependency, disorders of aggression or impulse control, or acute crises; some of these people may benefit from psychoanalysis after the crisis has been resolved.

Description

In both psychoanalysis and psychoanalytic psychotherapy, the therapist does not tell the patient how to solve problems or offer moral judgments. The focus of treatment is exploration of the patient’s mind and habitual thought patterns. Such therapy is termed “non-directed.” It is also “insight-oriented,” meaning that the goal of treatment is increased understanding of the sources of one’s inner conflicts and emotional problems. The basic techniques of psychoanalytical treatment include:

Therapist neutrality

Neutrality means that the analyst does not take sides in the patient’s conflicts, express feelings about the patient, or talk about his or her own life. Therapist neutrality is intended to help the patient stay focused on issues rather than be concerned with the therapist’s reactions. In psychoanalysis, the patient lies on a couch facing away from the therapist. In psychodynamic psychotherapy, however, the patient and therapist usually sit in comfortable chairs facing each other.

Free association

Free association means that the patient talks about whatever comes into mind without censoring or editing the flow of ideas or memories. Free association allows the patient to return to earlier or more childlike emotional states (“regress”). Regression is sometimes necessary in the formation of the therapeutic alliance. It also helps the analyst to understand the recurrent patterns of conflict in the patient’s life.

Therapeutic alliance and transference

Transference is the name that psychoanalysts use for the patient’s repetition of childlike ways of relating that were learned in early life. If the therapeutic alliance has been well established, the patient will begin to transfer thoughts and feelings connected with siblings, parents, or other influential figures to the therapist. Discussing the transference helps the patient gain insight into the ways in which he or she misreads or misperceives other people in present life.

Interpretation

In psychoanalytic treatment, the analyst is silent as much as possible, in order to encourage the patient’s free association. However, the analyst offers judiciously timed interpretations, in the form of verbal comments about the material that emerges in the sessions. The therapist uses interpretations in order to uncover the patient’s resistance to treatment, to discuss the patient’s transference feelings, or to confront the patient with inconsistencies. Interpretations may be either focused on present issues (“dynamic”) or intended to draw connections between the patient’s past and the present (“genetic”). The patient is also often encouraged to describe dreams and fantasies as sources of material for interpretation.

Working through

“Working through” occupies most of the work in psychoanalytic treatment after the transference has been formed and the patient has begun to acquire insights into his or her problems. Working through is a process in which the new awareness is repeatedly tested and “tried on for size” in other areas of the patient’s life. It allows the patient to understand the influence of the past on his or her present situation, to accept it emotionally as well as intellectually, and to use the new understanding to make changes in present life. Working through thus helps the patient to gain some measure of control over inner conflicts and to resolve them or minimize their power.
Although psychoanalytic treatment is primarily verbal, medications are sometimes used to stabilize patients with severe anxiety, depression, or other mood disorders during the analysis.

The cost of either psychoanalysis is very expensive. A full course of psychoanalysis usually requires three to four weekly sessions with a psychoanalyst over a period of three to five years. Each session or meeting typically costs between $100 to $250, depending on the location and the experience of the therapist. The increasing reluctance of most HMOs and other managed care organizations to pay for long-term psychotherapy is one reason that these forms of treatment are losing ground to short-term methods of treatment and the use of medications to control the patient’s emotional symptoms.

Preparation

Some patients may need evaluation for possible medical problems before entering psychoanalysis because numerous diseases-including virus infections and certain vitamin deficiencies-have emotional side effects or symptoms. The therapist will also want to know whether the patient is taking any prescription medications that may affect the patient’s feelings or ability to concentrate. In addition, it is important to make sure that the patient is not abusing drugs or alcohol.

Risks

The primary risk to the patient is related to the emotional pain resulting from new insights and changes in long-standing behavior patterns. In some patients, psychoanalysis produces so much anxiety that they cannot continue with this treatment method. In other cases, the therapist’s lack of skill or differences in cultural background may prevent the formation of a solid therapeutic alliance.

Good Results

In general, this approach to treatment is considered successful if the patient has shown:

• Reduction in intensity or number of symptoms
• Some resolution of basic emotional conflicts
• Increased independence and self-esteem
• Improved functioning and adaptation to life

Attempts to compare the effectiveness of psychoanalytic treatment to other modes of therapy are difficult to evaluate. Some aspects of Freudian theory have been questioned since the 1970s on the grounds of their limited applicability to women and to people from non-Western cultures. In particular, some psychiatrists with cross-cultural experience maintain that psychoanalysis presupposes a highly individualistic Western concept of human personhood that is alien to traditional Asian and African societies. There is, however, general agreement psychoanalytic approaches work well for certain types of patients, specifically those with neurotic conflicts.

Psychoanalytic knowledge is the basis of all other dynamic approaches to therapy. Whatever the modifications, the insights of psychoanalysis form the underpinnings of much of the psychotherapy employed in general psychiatric practice, in child psychiatry, and in most other individual, family, and group therapies.

The Psychoanalytic Tradition

Sigmund Freud was the first psychoanalyst. Many of his insights into the human mind, which seemed so revolutionary at the turn of the century, are now widely accepted by most schools of psychological thought. Although others before and during his time had begun to recognize the role of unconscious mental activity, Freud was the preeminent pioneer in understanding its importance. Through his extensive work with patients and through his theory building, he showed that factors which influence thought and action exist outside of awareness, that unconscious conflict plays a part in determining both normal and abnormal behavior, and that the past shapes the present. Although his ideas met with antagonism and resistance, Freud believed deeply in the value of his discoveries and rarely simplified or exaggerated them for the sake of popular acceptance. He saw that those who sought to change themselves or others must face realistic difficulties. But he also showed us that, while the dark and blind forces in human nature sometimes seem overwhelming, psychological understanding, by enlarging the realm of reason and responsibility, can make a substantial difference to troubled individuals and even to civilization as a whole.

Building on such ideas and ideals, psychoanalysis has continued to grow and develop as a general theory of human mental functioning, while always maintaining a profound respect for the uniqueness of each individual life. Ferment, change, and new ideas have enriched the field, and psychoanalytic practice has adapted and expanded. Psychoanalysts today still appreciate the persistent power of the irrational in shaping or limiting human lives, and they therefore remain skeptical of the quick cure, the deceptively easy answer, the trendy or sensationalistic. Like Freud, they believe that psychoanalysis is the strongest and most sophisticated tool for obtaining further knowledge of the mind, and that by using this knowledge for greater self-awareness, patients free themselves from incapacitating suffering, and improve and deepen human relationships.

Who Can Benefit from Psychoanalysis?

Because analysis is a highly individualized treatment, people who wish to know if they would benefit from it should seek consultation with an experienced psychoanalyst. Still, some generalizations can be made. The person best able to undergo psychoanalysis is someone who, no matter how incapacitated at the time, is or potentially, a sturdy individual. This person may have already achieved important satisfactions – with friends, in marriage, in work, or through special interests and hobbies – but is nonetheless significantly impaired by long-standing symptoms: depression or anxiety, sexual incapacities, or physical symptoms without any demonstrable underlying physical cause. Private rituals or compulsions or repetitive thoughts of which no one else is aware may plague one person. Another may live a constricted life of isolation and loneliness, incapable of feeling close to anyone. A victim of childhood sexual abuse might suffer from an inability to trust others. Some people come to analysis because of repeated failures in work or in love, brought about not by chance but by self- destructive patterns of behavior. Others need analysis because the way they are – their character – substantially limits their choices and their pleasures. Still others seek analysis to resolve psychological problems that were only temporarily or partially resolved by other approaches.

Whatever the problem – and each is different – that a person brings to the analyst, it can be properly understood only within the context of that person’s strengths and life situation. Hence, the need for a thorough evaluation to determine who will benefit – and who will not – from psychoanalysis.

Who is a Psychoanalyst?

Federal or state law does not protect the designation “psychoanalyst”: anyone, even an untrained person, may use the title. It is therefore important to know the practitioner’s credentials before beginning treatment. Graduate psychoanalysts trained under the auspices of the American Psychoanalytic Association have had very rigorous and extensive clinical education. Candidates accepted for training at an accredited psychoanalytic institute must meet high ethical, psychological, and professional standards. These candidates are either physicians who have completed a four-year residency program in psychiatry, psychologists or social workers who have completed a doctoral program in their fields or hold a clinical masters degree in a mental health field where such a degree is generally recognized as the highest clinical degree; all must have had extensive clinical experience. Outstandingly qualified scholar-researchers, educators, and selected other professionals may also be approved for psychoanalytic training. All accepted candidates, whatever their background, then begin at least four years of psychoanalytic training.

This training consists of three parts. Candidates attend classes in psychoanalytic theory and technique. They undergo a personal analysis. Moreover, they conduct the psychoanalysis of at least three patients under the close and extended supervision of experienced analysts.
Besides conducting psychoanalysis, most graduate analysts also practice intensive and brief psychotherapy, sometimes prescribing medication. Many treat couples, conduct family or group therapy sessions, and work with the aging.

Because psychoanalysts are provided with the most thorough education available in normal and pathological development, their training enhances the quality of all of their therapeutic work. It also informs their community activities as teachers, supervisors, consultants, and researchers, in the many different settings – hospitals, medical schools, colleges, day-care centers – where analysts are found.

Relational psychoanalysis is a school of psychoanalysis in the United States in which the role of real and imagined relationships with others is emphasized.
Relational psychoanalysis began in the 1980’s as an attempt to integrate interpersonal psychoanalysis’s emphasis on the detailed exploration of interpersonal interactions with British object relations theory’s sophisticated ideas about the psychological importance of internalized relationships with other people. Relationalists argue that personality emerges out of the matrix of early formative relationships with parents and other figures. Philosophically, relational psychoanalysis is closely allied with social constructionism.

An important difference between relational theory and traditional psychoanalytic thought is its theory of motivation. Freudian theory, with a few exceptions, proposes that human beings are motivated by sexual and aggressive drives. These drives are biologically rooted and innate. They are ultimately not shaped by experience.
Object Relationalists, on the other hand, argue that the primary motivation of the psyche is to be in relationships with others. Consequently, early relationships, usually with primary caregivers, shape one’s expectations about the way in which one’s needs are met. Therefore, desires and urges cannot be separated from the relational contexts in which they arise. This does not mean that motivation is determined by the environment (as in behaviorism), but that motivation is determined by the systemic interaction of a person and his or her relational world. Individuals attempt to recreate these early-learned relationships in ongoing relationships that may have little or nothing to do with those early relationships. This recreation of relational patterns serves to satisfy the individual’s needs in a way that conforms to what they learned as an infant. This recreation is called an enactment.

When treating patients, relational psychoanalysts stress a mixture of waiting, and authentic spontaneity. Some relationally oriented psychoanalysts eschew the traditional Freudian emphasis on interpretation and free association, instead emphazing the importance of creating a lively, genuine relationship with the patient. However, many others place a great deal of importance on the Winnecottian concept of “holding” and are far more restrained in their approach, generally giving weight to well formulated, well timed. Overall, Relational analysts feel that psychotherapy works best when the therapist focuses on establishing a healing relationship with the patient, in addition to focusing on facilitating insight. They believe that in doing so, therapists break patients out of the repetitive patterns of relating to others that they believe maintain psychopathology.

Key Terms

Free association: A technique used in psychoanalysis in which the patient allows thoughts and feelings to emerge without trying to organize or censor them.

Interpretation: A verbal comment made by the analyst in response to the patient’s free association. It is intended to help the patient gain new insights.

Neurosis: A mental and emotional disorder that affects only part of the personality is accompanied by a significantly less distorted perception of reality than in psychosis.

Regression: The process by which the patient reverts to earlier or less mature feelings and behaviors.

Therapeutic alliance: The working relationship between a therapist and a patient that is necessary to the success of therapy.

Transference: The process that develops during psychoanalytic work during which the patient redirects feelings about early life figures toward the analyst.

Working through

The repeated testing of insights, which takes up most of the work in psychoanalysis after the therapeutic alliance has been formed.

References:
1- Blass, R. B. “On Ethical Issues at the Foundation of the Debate Over the Goals of Psychoanalysis.” International Journal of Psychoanalysis 84 (August 2003): 929-943.
2- Gabbard, G. O., and D. Westen. “Rethinking Therapeutic Action.” International Journal of Psychoanalysis 84 (August 2003): 823-841.
3- Lombardi, R. “Mental Models and Language Registers in the Psychoanalysis of Psychosis: An Overview of a Thirteen-Year Analysis.” International Journal of Psychoanalysis 84 (August 2003): 843-863. Roland, A. “Psychoanalysis Across Civilizations: A Personal Journey.” Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 31 (Summer) This Essay is adapted from an essay by Rebecca J. Frey, PhD.

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